MCN NCP

I.
CARE PLAN
ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

THE PROBLEM
S The nursing Goal: Patient will Dx: FULLY met if:
>productive cough diagnosis of Ineffective maintain clear, open Assess respiration. The patient is able to
A change in the usual
*few hours PTA Airway Clearance is airways as evidenced by Note quality, rate, maintain the airway patency
respiration may mean
>persistence of above defined as the inability to normal breath sounds, pattern, depth, flaring as evidenced by clear breath
respiratory compromise.
symptoms clear secretions or normal rate and depth of of nostrils, dyspnea sound, normal respiratory
An increase in respiratory
>DOB and pale skin (pallor) obstructions from the respirations, and ability to on exertion, evidence depth and rate, and noiseless
rate and rhythm may be a
respiratory tract to effectively cough up of splinting, use of respiration.
compensatory response to
O maintain a clear airway. secretions after treatments accessory muscles, PARTIALLY met if:
airway obstruction.
Vital Signs (NANDA, 2019) and deep breaths. and position for The patient is able to
>SPO2 = 87% breathing. maintain almost the airway
>RR=48cpm Upon ausculatation STO patency as evidenced by few
crackles are heard on the - Within 10 minutes of crackles in breath sound,
>deep breaths right lower lobes of the health teachings, the normal respiratory depth and
>auscultation of lung sounds lungs due to retained patient’s rate, and presence of noise
(crackles) secretions of the patient. parents/family will Increased work of during respiration.
Note for changes in
Secretions is still eminent identify and avoid breathing can lead to NOT met if:
hear rate and
Nursing Diagnosis: that the patient has not specific factors that tachycardia . Retained The patient is not able to
temperature.
Ineffective Airway Clearance expoctorated all secretions inhibit effective airway secretions may be a sign maintain the airway patency
related to retained secretions brought about by clearance. of an existing infection or as evidenced by crackles in
pneumonia. - recognize the inflammatory process breath sound, irregular
significance of changes in manifested by a fever or respiratory depth and rate,
Mechanisms that exist in sputum to include color, increased temperature. and presence of noise during
the lower bronchioles and character, amount, and respiration.
alveoli to maintain the odor.
patency of the airway
Use pulse oximetry Pulse oximetry is used to
include the mucociliary LTO
to monitor oxygen detect changes in
system ,macrophages, and - Within 3 days of
saturation oxygenation.
the lymphatics. When nursing interventions, the
mucociliary is impaired patient will manifest
due to mucus plug this clear, open airways as
1
allow invasive bacteria to evidenced by normal
adhere and colonize the breath sounds, normal
Abnormal breath sounds
airways. This affects the air rate and depth of Auscultate lungs for
can be heard as fluid and
sacs or alveoli in respirations, and ability to presence of normal
mucus accumulate. This
exchanging gases in the effectively cough up or adventitious
may indicate ineffective
lungs and causes it to have secretions after treatments breath sounds.
airway clearance.
ineffective airway and deep breaths.
clearance.
Tx:
Upright position limits
Community acquired Position the patient
abdominal contents from
pneumonia is one of the with the head
pushing upward and
most common serious elevated if tolerated.
inhibiting lung expansion.
infections in children Regularly check the
This position promotes
especially in infants. patient’s position to
better lung expansion and
Streptococcus pneumoniae prevent sliding down
improved air exchange.
and viruses are the most in bed.
common causes in infants
Bronchial tapping helps
three weeks to three
mobilize bronchial
months of age.when
Perform bronchial secretion from smaller
exposes to Due to their
tapping airways that cannot be
weak immune system
eliminated by means of
bacteria or viruses can
coughing or suctioning.
easily enter the airway.
A variety of medications
Give medications as are prepared to manage
prescribed, such as specific problems. Most
ampicillin , promote clearance of
amikacin,paracetamo airway secretions and
l, salbutamol, and N- may reduce airway
Acetyl Cystein . resistance.
2
Ed: Fluids such as breast milk
Advise the mother to helps minimize the mucosal
breastfeed drying and maximize ciliary
continuously. action to move secretion. It
also facilitates easy
elimination of secretion.
Advise the client’s

significant others to
comply with annual
check up required for
the client.
Vinegar is a natural and

Instruct the client’s powerful cleaner that
significant others to deodorizes, kills mildew
clean walls with and do not emit any harsh
vinegar and water fumes. Thus, providing a
natural killer for
Reitterate the
importance of hand Hand hygiene prevents
hygiene before spread of infection
holding the baby.
3
References:
 Tortora, G. & Derrickson, B. (2014). Principles of Anatomy and Physiology.14th Edition. John Wiley and Sons.pdf
 Berman, A. et al. (2016). Kozier and Erb’s Fundamentals of Nursing: Concepts Process and Practice. 10th Edition. Pearson Education Incorporation.pdf
 Kokai, D. et al. (2018). N-acetyl-cysteine increases the replication of Chlamydia pneumoniae and prolongs the clearance of the pathogen from mice. Journal of Medical
Microbiology. DOI 10.1099/jmm.0.000716.pdf
 Bell, D. & Jones, J. (n.d.). Reticular and linear pulmonary opacification. Retrieved from. https://radiopaedia.org/articles/reticular-and-linear-pulmonary-opacification?
lang=us
 Bennett, N. J. (2018). Imaging in Pediatric Pneumonia. Retrieved from. https://emedicine.medscape.com/article/1926980-overview
 Drugbank. (2019). Salbutamol. Retrieved from. https://www.drugbank.ca/drugs/DB01001
 Sabtu. (2013). Ineffective airway clearance. Retrieved from http://nursinginterventionsrationales.blogspot.com/2013/07/ineffective-airway-clearance.html

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I.

ASSESSMENT EXPLANATION OF OBJECTIVES INTERVENTIONS RATIONALE EVALUATION

Advise the client’s

Vinegar is a natural and

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